CENTRO DE CUIDADO PROLONGADO SAN LUCAS
CARR 844 KM 0 5 CUPEY, RIO PIEDRAS, PR, 00928 · 7877618383
Legal business name: SAN LUCAS METRO, INC.
On the CMS record
- Overall rating (CMS)
- 1 / 5
- Health inspection rating
- 1 / 5
- Staffing rating
- 1 / 5
- Certified beds
- 25
- Ownership type
- Non profit - Church related
Inspection findings on record (86)
Quoted exactly as CMS published them. We do not rewrite findings.
— Nutrition and Dietary Deficiencies
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Recorded as corrected on .
— Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Recorded as corrected on .
— Environmental Deficiencies
Keep all essential equipment working safely.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Recorded as corrected on .
— Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Recorded as corrected on .
— Nursing and Physician Services Deficiencies
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Recorded as corrected on .
— Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Recorded as corrected on .
— Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Recorded as corrected on .
— Nursing and Physician Services Deficiencies
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Recorded as corrected on .
— Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Recorded as corrected on .
— Administration Deficiencies
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Recorded as corrected on .
— Resident Rights Deficiencies
Give the resident's representative the ability to exercise the resident's rights.
Recorded as corrected on .
— Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Recorded as corrected on .
— Resident Rights Deficiencies
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Recorded as corrected on .
— Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to choose his or her attending physician.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Recorded as corrected on .
— Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Recorded as corrected on .
— Resident Rights Deficiencies
Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Recorded as corrected on .
— Resident Rights Deficiencies
Provide immediate access to any resident.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Recorded as corrected on .
— Resident Rights Deficiencies
Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
Recorded as corrected on .
— Resident Rights Deficiencies
1) Protect residents from being forced to work at the nursing home, or 2) let residents work if they want to.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to manage his or her financial affairs.
Recorded as corrected on .
— Resident Rights Deficiencies
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Recorded as corrected on .
— Resident Rights Deficiencies
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Recorded as corrected on .
— Resident Rights Deficiencies
Assure the security of all personal funds of residents deposited with the facility.
Recorded as corrected on .
— Resident Rights Deficiencies
Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
Recorded as corrected on .
— Resident Rights Deficiencies
Give residents a notice of rights, rules, services and charges.
Recorded as corrected on .
— Resident Rights Deficiencies
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Recorded as corrected on .
— Resident Rights Deficiencies
The resident has the right to receive notices in a format and a language he or she understands.
Recorded as corrected on .
— Resident Rights Deficiencies
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Recorded as corrected on .
— Resident Rights Deficiencies
Ensure residents have reasonable access to and privacy in their use of communication methods.
Recorded as corrected on .
— Resident Rights Deficiencies
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Recorded as corrected on .
— Resident Rights Deficiencies
Provide information about how to apply for and use Medicare and Medicaid benefits.
Recorded as corrected on .
— Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Recorded as corrected on .
— Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Recorded as corrected on .
— Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Recorded as corrected on .
— Resident Rights Deficiencies
Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate care/assistance for a resident with a prosthesis.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide care or services that was trauma informed and/or culturally competent.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Recorded as corrected on .
— Administration Deficiencies
Provide timely, quality laboratory services/tests to meet the needs of residents.
Recorded as corrected on .
— Administration Deficiencies
Ensure laboratory services, blood blanks and transfusion services provided on-site meet requirements for certified laboratories.
Recorded as corrected on .
— Administration Deficiencies
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide routine and 24-hour emergency dental care for each resident.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide or get specialized rehabilitative services as required for a resident.
Recorded as corrected on .
— Administration Deficiencies
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Recorded as corrected on .
— Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Recorded as corrected on .
— Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Recorded as corrected on .
— Infection Control Deficiencies
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Recorded as corrected on .
— Administration Deficiencies
Have a Compliance and Ethics Program.
Recorded as corrected on .
— Environmental Deficiencies
Keep all essential equipment working safely.
Recorded as corrected on .
— Environmental Deficiencies
Put firmly secured handrails on each side of hallways.
Recorded as corrected on .
— Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Recorded as corrected on .
— Administration Deficiencies
Provide training in compliance and ethics.
Recorded as corrected on .
— Administration Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Recorded as corrected on .
Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 405033